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The baseline electrocardiogram showed nearly incessant runs of atrial tachycardia in all patients. The mean atrial ectopic cycle length ranged from 376 to 502 ms. In seven patients a progressive prolongation of the cycle length from the beginning to the end of the salvos was documented. The arrhythmia was suppressed by increments of sinus node rate and by atrial pacing at cycle lengths longer than that of the atrial tachycardia. In all patients the arrhythmia was abolished by intravenous lidocaine, whereas intravenous verapamil was ineffective. Four symptomatic patients were successfully treated with radiofrequency ablation of the ectopic focus, and two patients were treated with oral mexiletine.
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Pharmacological treatment of hypertension is effective in preventing cardiovascular and renal complications. Calcium antagonists (CAs) and blockers of the renin-angiotensin system [angiotensin-converting enzyme (ACE) inhibitors and angiotensin II antagonists (ARBs)] are widely used today to initiate antihypertensive treatment but, when given as monotherapy, do not suffice in most patients to normalise blood pressure (BP). Combining a CA and either an ACE-inhibitor or an ARB considerably increases the antihypertensive efficacy, but not at the expense of a deterioration of tolerability. Several fixed-dose combinations are available (CA + ACE-inhibitors: amlodipine + benazepril, felodipine + ramipril, verapamil + trandolapril; CA + ARB: amlodipine + valsartan). They are expected not only to improve BP control, but also to facilitate long-term adherence with antihypertensive therapy, thereby providing maximal protection against the cardiovascular and renal damage caused by high BP.
Despite the availability of many newer antihypertensive agents, hypertensive patients remain at a higher risk of premature death than the general population. This persistence of elevated morbidity and mortality may be accounted for by the frequent failure to achieve adequate blood pressure reduction despite an extensive range of available antihypertensive agents. Such considerations have led to the reassessment of the potential role of fixed-dose combination agents. The antihypertensive efficacy may be enhanced when two classes of agents are combined. In addition, combination therapy enhances tolerability because one drug of fixed combination can antagonize some of the adverse effects of the second drug. Fixed-dose combination therapy simplifies the treatment regimen, preventing treatment failures that might result from missed doses.
The human multidrug transporter P-glycoprotein (Pgp, ABCB1) contributes to the poor bioavailability of many anticancer and antimicrobial agents as well as to drug resistance at the cellular level. For rational design of effective Pgp inhibitors, a clear understanding of its mechanism of action and functional regulation is essential. In this study, we demonstrate that inhibition of Pgp-mediated drug transport by cis-(Z)-flupentixol, a thioxanthene derivative, occurs through an allosteric mechanism. Unlike competitive inhibitors, such as cyclosporin A and verapamil, cis-(Z)-flupentixol does not interfere with substrate ([(125)I]iodoarylazidoprazosin) recognition by Pgp, instead it prevents substrate translocation and dissociation, resulting in a stable but reversible Pgp-substrate complex. cis-(Z)-Flupentixol-induced complex formation requires involvement of the Pgp substrate site, because agents that either physically compete (cyclosporin A) for or indirectly occlude (vanadate) the substrate-binding site prevent formation of the complex. Allosteric modulation by cis-(Z)-flupentixol involves a conformational change in Pgp detectable by monoclonal antibody UIC2 binding to a conformation-sensitive external epitope of Pgp. The conformational change observed is distinct from that induced by Pgp substrates or competitive inhibitors. A single amino acid substitution (F983A) in TM12 of Pgp that impairs inhibition by cis-(Z)-flupentixol of Pgp-mediated drug transport also affects stabilization of the Pgp-substrate complex as well as the characteristic conformational change. Taken together, our results describe the molecular mechanism by which the Pgp modulator cis-(Z)-flupentixol allosterically inhibits drug transport.
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P-glycoprotein (Pgp), the MDR-encoded membrane transporter, is physiologically expressed in normal tissues with excretory functions, including kidney proximal tubules. In a preliminary report we have shown that HK-2, an immortalized cell line from normal human proximal tubule, expresses a functional Pgp and may be considered a valuable model for in vitro investigations on the Pgp role(s) in human renal pathophysiology. The present investigation was designed to further characterize the properties of HK-2 Pgp by exploring its responsiveness to a variety of exogenous or endogenous modulators. HK-2 cells were cultured in Dulbecco's modified Eagle's medium/Ham's F-12 supplemented with 5% FCS in the absence or in the presence of modulators. Pgp mRNA expression was studied by RT-PCR and the amount of Pgp was determined by Western blotting. Pgp activity was assessed by intracellular rhodamine-123 (R-123) accumulation. RT-PCR showed that HK-2 cells express MDR-1, but not MDR-3. Both MDR-1 Pgp and MDR-1 mRNA were significantly increased in cells cultured in the presence of cyclosporin A (CsA), 1,25(OH)(2)D(3), platelet activating factor, dexamethasone (Dex), or aldosterone. Verapamil (Vp), cimetidine, and trimethoprim did not affect HK-2 Pgp expression. Conversely, 2-acetylaminofluorene strongly downregulated Pgp expression. Vp, CsA, 1,25(OH)(2)D(3) and Dex significantly increased R-123 intracellular retention, indicating the inhibition of Pgp-mediated transport. Drug-pretreated, Pgp-overexpressing cells showed increased Pgp activity and were less susceptible to toxic concentrations of CsA. MDR-1 Pgp in HK-2 appears to be responsive to many compounds, including classical Pgp inhibitors and putative physiological substrates, but some of its pharmacological properties are different from those described in other experimental, in particular nonhuman, cell models.
Coronary and systemic hemodynamic effects of verapamil have been investigated previously in detail. The acute impact of intracoronary verapamil on coronary hemodynamics has, however, not been correlated to simultaneously changes in myocardial metabolism or norepinephrine levels in humans. After bolus application of 1 mg verapamil into the left coronary artery of 52 patients scheduled for routine coronary angiography, heart rate (HR) remained unchanged, whereas mean arterial blood pressure (MAP) decreased (93.8 +/- 14.9 mmHg to 85.1 +/- 13.7 mmHg, p = 0.001). Coronary blood flow (CBF), calculated from intracoronary Doppler measurements and quantitative coronary angiography, increased after verapamil administration (28.5 +/- 16.7 ml/min to 66.2 +/- 41.8 ml/min, p < 0.001), whereas coronary vascular resistance index (CVRI) decreased (1.43 +/- 0.92 to 0.46 +/- 0.23, p < 0.001). Blood samples, taken simultaneously from the aorta (Ao) and coronary sinus (CS) at baseline and at maximal flow velocity, showed an increase in norepinephrine concentrations in Ao (209 +/- 151 ng/l to 283 +/- 195 ng/l, p < 0.001) and CS (233 +/- 162 ng/l to 323 +/- 248 ng/l, p = 0.004). Myocardial metabolism of pyruvate and free fatty acids were not affected. Glucose release was augmented and initial lactate consumption changed to a net lactate release into the CS (Ao to CS differences: glucose: -1.92 +/- 9.9 mg/dl to -12.8 +/- 22.8 mg/dl, p < 0.001; lactate: 0.07 +/- 0.2 mmol/l to -0.08 +/- 0.3 mmol/l, p = 0.001). Similar results were obtained for the extraction ratios and flux of these metabolites. There was a weak correlation between the increase in CBF and lactate release into the CS. This is the first report of unexpected myocardial lactate release following intracoronary verapamil administration in humans. This lactate release was paralleled by an increased glucose release into the CS at an unchanged metabolism of free fatty acids and pyruvate. One explanation for this unexplained lactate release during increased coronary blood flow might be a wash out phenomenon of lactate from previous ischemic areas, other explanations might be the induction of paradox myocardial ischemia and/or a steal effect. Further studies are necessary to explain these unexpected findings of increased coronary flow and myocardial lactate release. Until reliable explanations are pending, studies using only lactate release as a marker of myocardial ischemia, without taken coronary and systemic hemodynamic parameters into account, should be interpreted with caution.
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The classical localisation of chromaffin cell tumours is intra-adrenal. Ectopic or multiple tumours are not rare and are commonly observed in children. The authors report a case of ectopic pheochromocytoma with a double localisation in a 14 year old child (renal pedicle and right retropleural space), in which surgical ablation resulted in an immediate and sustained correction of the hypertension. Hypertension recurred 24 years later and a classical right adrenal pheochromocytoma was demonstrated by methyl-iodo-benzylguanidine (M.I.B.G.) scintigraphy and abdominal CT scan. Right adrenalectomy resulted in normalisation of the hypertension once again without antihypertensive therapy with a follow-up of three years. Regular follow-up is necessary after ablation of a pheochromocytoma, especially in children, even in the absence of a phacomatosis or multiple endocrine neoplastic syndromes.
TAX-2'-Et transport was characterized in a human colon carcinoma cell line (Caco-2) and paclitaxel (TAX)-resistant ovarian carcinoma cells (SKOV3/TAX60). Expression of P-gp, multidrug resistance protein (MRP) 2 and Ra-CES was detected by Western blotting. Cytotoxicity against Ra-CES-expressing cells and cellular amount of TAX produced were determined by MTT assay and using HPLC, respectively.
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A verapamil-sensitive side population (SP) can be isolated from primary prostate tissue accounting for 1.38% +/- 0.07% of prostate epithelial cells. Cell cycle analysis of this SP population revealed that the majority of SP cells are in either G0 (12.38 +/- 0.31%) or G1 (63.19 +/- 2.13%).
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Candida albicans morphogenesis and gastrointestinal colonization are closely associated with the pathogenicity of this pathogen. This study investigated the in vitro and in vivo effect of verapamil, a calcium channel blocker, on these processes. Exposure to ≥ 10 μg mL(-1) verapamil led to a significant decrease of C. albicans hyphal cells. The ability to adhere to a polystyrene surface and buccal epithelial cells was inhibited by exposure to ≥ 20 μg mL(-1) verapamil. Detection of the Hwp1-green fluorescent protein fusion protein showed that verapamil inhibited expression and transport of Hwp1, indicating its activity against both the regulation network of morphogenesis-associated proteins and the secretory pathway in C. albicans. Moreover, treatment with verapamil at 10 mg (kg day)(-1) led to a remarkable decrease in gastrointestinal-colonizing fungal cells. This study revealed the inhibitory effect of verapamil on C. albicans hyphal development, adhesion and gastrointestinal colonization, which is relevant to decreased expression and abnormal transport of the proteins required for morphogenesis. Therefore, verapamil may be taken into account when choosing an antifungal therapy against C. albicans colonization and infection.
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For many years ECG disturbances caused by cardiologic drugs are in the spot of our interests. In the Poisoning Centers patients who ingested large amounts of these drugs are treated so there are possibilities to investigate such kind of ECG changes. For the demonstration we present ECG-s illustrating disturbances in the course of intoxication with calcium channel blockers, beta antagonists and digoxin.
The intrinsic nature of rthymic release of luteinizing hormone (LH) of isolated human and rat anterior pituitary gland reported independently by Macro Gambacciani and Xie in 1987 can be more directly demonstrated by a computer programme of Time Series-HSY Hidden Periodic Analytic Approach for continuous monitoring the LH output of the perfusate from a perfusion system with in vitro anterior pituitary of SD female rat. The results are as follows: (1) Under various reproductive conditions the average frequency (min/cycle) and amplitude (ng/ml) of the intrinsic rhythm of LH release were quite different: In proestrous group the frequency and amplitude were the highest, being intermediate in the ovariectomized group and lowest in the lactation group. (2) The intrinsic rhythm of LH release could be changed by either peptide or steroid hormones. In proestrous group with 30 min of gonadotropin-releasing hormone (GnRH), stimulation would reduce both frequency and amplitude. In case of lactation, the frequency was unchanged, but amplitude lowered, while in the ovariectomized rat pituitary, the 30 min GnRH stimulation decreased the frequency of release only. The intrinsic rhythm of the LH release could also be influenced by steriod hormones (Ru486 and Anordrin). With 120 min before removal of the anterior pituitary gland the rats receiving i.m. injection of Ru486 (2 mg/kg bw) or Anordrin (2 mg/kg), the results showed that Ru486 decreased frequency, while Anordrin decreased only the frequency to a less extent, both without amplitude affected. (3) Verapamil and EGTA added to the perfusion system did not abolish but only decreased the rhythmic phenomenon by using proestrous pitutary. This suggests that participation of Ca2+ may take place in the intrinsic release of LH. The above results indicated that the intrinsic rhythm of LH release of isolated anterior pituitary gland is different from various reproductive hormonal conditions and capable of being modified by exogenous hormones. The physiological function of the intrinsic rhythm of LH release of anterior pituitary gland remains to be elucidated.
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Twelve landrace-pigs were intoxicated with intravenous verapamil at escalating infusion rates. The infusion containing 2.5 mg/ml verapamil was used aiming to a reduction of cardiac output by 40% from the baseline value. Intoxicated pigs were randomized into two groups: control (saline) and levosimendan (intravenous bolus). Inotropic effect was measured as a change in a maximum of the positive slope of the left ventricular pressure (LV dP/dt). The survival and hemodynamics of the animals were followed for 120 min after the targeted reduction of cardiac output.
The intestinal absorption characteristics of anthraquinones emodin and chrysophanol were observed by measuring the intracellular accumulation across Caco-2 cells by the reverse-phase high performance liquid chromatography. The intracellular accumulation of chrysophanol was much greater than that of emodin, the maximum absorption of emodin and chrysophanol being 414.02+/-15.28 and 105.56+/-11.57 nmol/l x mg x protein, respectively. The absorption of each anthraquinone was significantly lower at 4 degrees C than that of 37 degrees C. The effects of the transport inhibitors, verapamil, cyclosporine and phloridzin, on the intracellular accumulation were also examined. Verapamil and cyclosporine increased the absorption of emodin and chrysophanol, while phloridzin inhibited their absorption, all in a dose-dependent manner. These results suggest that the absorption characteristics of emodin and chrysophanol were closely related to their special structure with the hydroxy groups. It is also likely that a specific transport system mediated the intracellular accumulation of emodin and chrysophanol across the Caco-2 cells.
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(18)F-FDG PET/CT can be used to detect arterial atherosclerotic plaque inflammation. However, avid myocardial glucose uptake may preclude its use for visualizing coronary plaques. Fatty acid loading or calcium channel blockers could decrease myocardial (18)F-FDG uptake, thus assisting coronary plaque inflammation identification. The present prospective randomized trial compared the efficacies of different interventions for suppressing myocardial (18)F-FDG uptake. We also investigated whether circulating free fatty acid (cFFA) levels predicted the magnitude of myocardial (18)F-FDG uptake.
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Fourteen patients (7 males and 7 females) with the diagnosis of acromegaly and diastolic dysfunction confirmed by echocardiogram were studied. After six months of treatment with verapamil (240 mg/day) the echo-cardiographic parameters and the functional class (NYHA) of patients were reevaluated.
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5-FU based treatments proved to be more ef cacious than the other modalities. 5-FU + TMC demonstrated the largest reduc- tion in keloid height and rmness. The greatest degree of scar softening and average size reduction was achieved with 5-FU/ TMC (80% and 70% reduction, respectively), followed by 5-FU/verapamil (50% and 33% reduction, respectively). The same combinations led to the greatest reduction in scar height (70% and 33%, respectively). All treatments led to resolution of pain and itching in the keloid.
The present study demonstrated that P-gp inhibition enhanced the intracerebral concentration of imipramine , thus supporting the hypothesis that P-gp activity restricts brain levels of certain antidepressants, including imipramine. These findings may help to explain reports of a beneficial response to adjunctive therapy with verapamil in TRD.
trans-Resveratrol, a natural antioxidant, has been described as a nutraceutic compound with important beneficial effects on health, but its low oral bioavailability hinders its therapeutic activity. Here, we studied the mechanisms of apical transport of trans-resveratrol in enterocytes and the role of ATP-binding cassette (ABC) transporters in the secretion of resveratrol glucuronide and sulfate resulting from the rapid intracellular metabolism. An intestinal perfusion method with recirculation in vivo was used in rats. Jejunal loops were perfused with increasing concentrations of trans-resveratrol and results showed that its uptake occurs by simple diffusion without the participation of a mediated transport. The apparent diffusion constant was 8.1 +/- 0.3 microL/(5 min.mg dry weight). The glycoprotein-P (Pgp, ABCB1), multidrug resistance-associated protein 2 (MRP2, ABCC2), and breast cancer resistance protein (BCRP, ABCG2) located in the apical membrane of enterocytes were investigated using specific inhibitors. The Pgp inhibitors verapamil (5 micromol/L) and cyclosporin A (5 micromol/L) did not affect the efflux of trans-resveratrol and its conjugates. The MRP2 inhibitors probenecid (2 mmol/L) and MK571 (10 micromol/L) reduced the efflux of glucuronide by 61 and 55%, respectively, and of sulfate by 43 and 28%, respectively. The BCRP inhibitor Ko143 (0.5 micromol/L) decreased the secretion of glucuronide by 64% and of sulfate by 46%. Our experiments identify MRP2 and BCRP as the 2 apical transporters involved in the efflux of resveratrol conjugates.
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Cross-sectional analysis of nationwide dispensing data. Odds ratios of interacting erythromycin, verapamil/diltiazem versus respective prevalence of comparator drugs doxycycline, amlodipine/felodipine in patients co-dispensed interacting statins simvastatin/atorvastatin versus patients unexposed (pravastatin/fluvastatin/rosuvastatin) was calculated. For fibrates, OR of gemfibrozil versus fenofibrate/bezafibrate in patients co-dispensed any statin was assessed.
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Multidrug resistance (MDR) is a pleiotropic resistance against several unrelated drugs. It may be induced by prolonged exposure of cells to drugs such as doxorubicin, etoposide and vinca alkaloids. Once MDR develops in clinical tumors, it is a major obstacle for the improvement of treatment of multiple myeloma (MM). Several specific mechanisms have been identified in clinical refractory MM patients including typical MDR, which is associated with P-glycoprotein (Pgp) and Lung Resistance Protein (LRP). The expression of the proteins associated with these genes seems to depend on exposure to chemotherapeutic agents. Recently, reversal of MDR by non-cytotoxic agents such as verapamil, cyclosporin A and PSC 833 (Valdospar) was explored in acute leukemia and multiple myeloma. Preliminary results from clinical phase I/II trials indicate that reversal of MDR is possible and that it may lead to alterations of the plasma pharmacokinetics of the cytostatic agents, in addition to P-glycoprotein inhibition in tumor cells. The potential implications of P-glycoprotein reversal are discussed.
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We evaluated the frequency of second- and third-degree AV block in patients with baseline first-degree AV block during adenosine stress testing, in the presence and absence of AV blocking medications (digitalis, beta-blockers, diltiazem, verapamil). Six hundred consecutive patients underwent pharmacologic stress myocardial perfusion imaging with adenosine infusion at 140 microg/kg/min for 6 minutes. A total of 43 patients (7.16%) had baseline first-degree AV block (PR interval > 200 msec), and 557 patients had a baseline PR interval < 200 msec. Twenty-one of the 43 patients (48.8 %) had further prolongation of PR interval > 240 msec, compared with 58 of 557 patients (10.4%) in the control group (P < .0001). In 16 of the 43 patients (37.3 %), second-degree AV block developed, compared with 45 of 557 patients (8.0 %) in the control group (P < .0001). In 6 of the 43 patients (13.9%), third-degree AV block developed, compared with 6 of 557 patients (1.0%) in the control group (P < .0001). All types of AV block were short duration and were not associated with any specific symptoms. None of these episodes required specific treatment. The presence of AV blocking medications (digitalis, beta-blockers, diltiazem, verapamil) did not increase the incidence of AV block during adenosine infusion.